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Zomar BO, Bone JN, Nguyen V, Mulpuri K, Kelley S, Schaeffer EK. Comparison of brace to observation in stable, radiological developmental dysplasia of the hip: a protocol for a global multicentre non-inferiority randomised trial. BMJ Open 2024; 14:e084738. [PMID: 38977361 PMCID: PMC11256031 DOI: 10.1136/bmjopen-2024-084738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/09/2024] [Indexed: 07/10/2024] Open
Abstract
INTRODUCTION Brace treatment is common to address radiological dysplasia in infants with developmental dysplasia of the hip (DDH); however, it is unclear whether bracing provides significant benefit above careful observation by ultrasound. If observation alone is non-inferior to bracing for radiological dysplasia, unnecessary treatment may be avoided. Therefore, the purpose of this study is to determine whether observation is non-inferior to bracing for infants with radiological dysplasia. METHODS AND ANALYSIS This will be a multicentre, global, randomised, non-inferiority trial performed under the auspices of a global prospective registry for infants and children diagnosed with DDH. Patients will be included if they present with radiological dysplasia (centred hip, alpha angle 43-60°, percent femoral head coverage greater than 35% measured on ultrasound) of a clinically stable hip under 3 months old. Patients will be excluded if they present with clinical hip instability, have received prior treatment or have known/suspected neuromuscular, collagen, chromosomal or lower-extremity congenital abnormalities or syndromic-associated hip abnormalities. Patients will be enrolled and randomised to undergo observation alone or brace treatment with a Pavlik harness for a minimum of 6 weeks. Follow-up visits will occur at 6 weeks, 1 year and 2 years post-enrolment. The primary outcome will be the norm-referenced acetabular index measured on the 2-year radiograph with a 3° non-inferiority margin. A total of 514 patients will be included.The study is anticipated to start in April 2024 and end in September 2028.The primary outcome will be compared between arms with a mixed-effects model with a random intercept for study centre, and a single covariate for the treatment group. If the lower bound of the 95% CI lies within 3° of the mean, we will treat this as evidence for non-inferiority. ETHICS AND DISSEMINATION Ethics approval has been obtained from the lead site's ethics board (University of British Columbia, Children's and Women's Research Ethics Board). Ethics approval will be obtained from the local ethics committees or institutional review boards at each institution prior to patient enrolment. It is intended that the results of this study shall be published in peer-reviewed journals and presented at suitable conferences. TRIAL REGISTRATION NUMBER NCT05869851.
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Affiliation(s)
- Bryn O Zomar
- Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
- Orthopaedic Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Vuong Nguyen
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Kishore Mulpuri
- Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
- Orthopaedic Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Simon Kelley
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Emily K Schaeffer
- Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
- Orthopaedic Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
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Saeed A, Bradley CS, Verma Y, Kelley SP. Resolving residual acetabular dysplasia following successful brace treatment for developmental dysplasia of the hip in infants. Bone Joint J 2024; 106-B:744-750. [PMID: 38945534 DOI: 10.1302/0301-620x.106b7.bjj-2023-1169.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Aims Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing. Methods This was a single-centre, prospective longitudinal cohort study of infants with DDH managed using a published, standardized Pavlik harness protocol between January 2012 and December 2016. RAD was measured at two years' mean follow-up using acetabular index-lateral edge (AI-L) and acetabular index-sourcil (AI-S), and at five years using AI-L, AI-S, centre-edge angle (CEA), and acetabular depth ratio (ADR). Each hip was classified based on published normative values for normal, borderline (1 to 2 standard deviations (SDs)), or dysplastic (> 2 SDs) based on sex, age, and laterality. Results Of 202 infants who completed the protocol, 181 (90%) had two and five years' follow-up radiographs. At two years, in 304 initially pathological hips, the prevalence of RAD (dysplastic) was 10% and RAD (borderline) was 30%. At five years, RAD (dysplastic) decreased to 1% to 3% and RAD (borderline) decreased to < 1% to 2%. On logistic regression, no variables were predictive of RAD at two years. Only AI-L at two years was predictive of RAD at five years (p < 0.001). If both hips were normal at two years' follow-up (n = 96), all remained normal at five years. In those with bilateral borderline hips at two years (n = 21), only two were borderline at five years, none were dysplastic. In those with either borderline-dysplastic or bilateral dysplasia at two years (n = 26), three (12%) were dysplastic at five years. Conclusion The majority of patients with RAD at two years post-brace treatment, spontaneously resolved by five years. Therefore, children with normal radiographs at two years post-brace treatment can be discharged. Targeted follow-up for those with abnormal AI-L at two years will identify the few who may benefit from surgical correction at five years' follow-up.
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Affiliation(s)
- Ayesha Saeed
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Catharine S Bradley
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Yashvi Verma
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Simon P Kelley
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
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Bradley CS, Verma Y, Maddock CL, Wedge JH, Gargan MF, Kelley SP. A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants. Bone Joint J 2023; 105-B:935-942. [PMID: 37524345 DOI: 10.1302/0301-620x.105b8.bjj-2023-0149.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Aims Brace treatment is the cornerstone of managing developmental dysplasia of the hip (DDH), yet there is a lack of evidence-based treatment protocols, which results in wide variations in practice. To resolve this, we have developed a comprehensive nonoperative treatment protocol conforming to published consensus principles, with well-defined a priori criteria for inclusion and successful treatment. Methods This was a single-centre, prospective, longitudinal cohort study of a consecutive series of infants with ultrasound-confirmed DDH who underwent a comprehensive nonoperative brace management protocol in a unified multidisciplinary clinic between January 2012 and December 2016 with five-year follow-up radiographs. The radiological outcomes were acetabular index-lateral edge (AI-L), acetabular index-sourcil (AI-S), centre-edge angle (CEA), acetabular depth ratio (ADR), International Hip Dysplasia Institute (IHDI) grade, and evidence of avascular necrosis (AVN). At five years, each hip was classified as normal (< 1 SD), borderline dysplastic (1 to 2 SDs), or dysplastic (> 2 SDs) based on validated radiological norm-referenced values. Results Of 993 infants assessed clinically and sonographically, 21% (212 infants, 354 abnormal hips) had DDH and were included. Of these, 95% (202 infants, 335 hips) successfully completed bracing, and 5% (ten infants, 19 hips) failed bracing due to irreducible hip(s). The success rate of bracing for unilateral dislocations was 88% (45/51 infants) and for bilateral dislocations 83% (20/24 infants). The femoral nerve palsy rate was 1% (2/212 infants). At five-year follow-up (mean 63 months (SD 5.9; 49 to 83)) the prevalence of residual dysplasia after successful brace treatment was 1.6% (5/312 hips). All hips were IHDI grade I and none had AVN. Four children (4/186; 2%) subsequently underwent surgery for residual dysplasia. Conclusion Our comprehensive protocol for nonoperative treatment of infant DDH has shown high rates of success and extremely low rates of residual dysplasia at a mean age of five years.
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Affiliation(s)
- Catharine S Bradley
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Yashvi Verma
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Connor L Maddock
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - John H Wedge
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Martin F Gargan
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Simon P Kelley
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
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Behman AL, Bradley CS, Maddock CL, Sharma S, Kelley SP. Testing of an Ultrasound-Limited Imaging Protocol for Pavlik harness Supervision (TULIPPS) in developmental dysplasia of the hip: a randomized controlled trial. Bone Joint J 2022; 104-B:1081-1088. [PMID: 36047018 DOI: 10.1302/0301-620x.104b9.bjj-2022-0350.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring. METHODS This study was a single-centre noninferiority randomized controlled trial. Infants aged under six months whose hips were reduced and centred in the harness at initiation of treatment (stable dysplastic or subluxable), or initially decentred (subluxated or dislocated) but reduced and centred within four weeks of PH treatment, were randomized to our current standard US monitoring protocol (every clinic visit) or to a limited-frequency US protocol (US only at end of treatment). Groups were compared based on α angle and femoral head coverage at the end of PH treatment, acetabular indices, and International Hip Dysplasia Institute (IHDI) grade on one-year follow-up radiographs. RESULTS Overall, 100 patients were included; 42 patients completed the standard protocol (SP) and 40 completed the limited protocol (LP). There was no significant difference in mean right α angle at the end of treatment (SP 70.0° (SD 3.2°) ; LP 68.7° (SD 2.9°); p = 0.033), nor on the left (SP 69.0° (SD 3.5°); LP 68.1° (SD 3.3°); p = 0.128). There was no significant difference in mean right acetabular index at follow-up (SP 23.1° (SD 4.3°); LP 22.0° (SD 4.1°); p = 0.129), nor on the left (SP 23.3° (SD 4.2°); LP 22.8° (SD 3.9°); p = 0.284). All hips had femoral head coverage of > 50% at end of treatment, and all were IHDI grade 1 at follow-up. In addition, the LP group underwent a 60% reduction in US use once stable. CONCLUSION Our study supports reducing the frequency of US assessment during PH treatment of DDH once a hip is reduced and centred.Cite this article: Bone Joint J 2022;104-B(9):1081-1088.
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Affiliation(s)
- Amy L Behman
- Department of Surgery, University of Toronto, Toronto, Canada.,Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Catharine S Bradley
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Connor L Maddock
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Smriti Sharma
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Simon P Kelley
- Department of Surgery, University of Toronto, Toronto, Canada.,Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
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Striano B, Schaeffer EK, Matheney TH, Upasani VV, Price CT, Mulpuri K, Sankar WN. Ultrasound Characteristics of Clinically Dislocated But Reducible Hips With DDH. J Pediatr Orthop 2019; 39:453-457. [PMID: 31503230 DOI: 10.1097/bpo.0000000000001048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although ultrasound (US) is frequently used in diagnosis and management of infantile developmental dysplasia of the hip, precise ultrasonographic parameters of what constitutes a dislocation, subluxation etc remain poorly defined. The purpose of this study was (1) to describe the ultrasonographic characteristics of a large cohort of clinically dislocated but reducible hips and (2) to begin to develop ultrasonographic definitions for what constitutes a hip dislocation. METHODS A retrospective review of prospectively collected data from an international multicenter study group on developmental dysplasia of the hip was conducted on all patients under 6 months of age with hip(s) that were dislocated at rest but reducible based on initial physical examination (ie, Ortolani positive). Femoral head coverage (FHC), alpha angle (α), and beta angle (β) were measured on pretreatment US by the individual treating surgeon, and were recorded directly into the database. RESULTS Based on 325 Ortolani positive hips, the median FHC on presentation was 10% with an interquartile range of 0% to 23%. A total of 126 of the 327 hips (39%) demonstrated 0% FHC. The 90th percentile was found to be at 33% FHC. Of 264 hips with sufficient α data, the median α was 43 degrees with an interquartile range from 37 to 49 degrees. The 90th percentile for α was at 54 degrees. A total of 164 hips had documented β with a median of 66 degrees and an interquartile range of 57 to 79 degrees; the 90th percentile was at 94 degrees. CONCLUSIONS Analysis of a large cohort of patients with dislocated but reducible hips reveals a median percent FHC of 10%, a median α of 43 degrees, and a median β of 66 degrees on initial US. Using a threshold at the 90th percentile, a sensible ultrasonographic definition of a dislocated hip seems to be FHC≤33%, implying that FHC between 34% and 50% may be reasonably termed a subluxation. Although these findings are consistent with previous, smaller reports, further prospective research is necessary to validate these thresholds. LEVEL OF EVIDENCE Level IV-diagnostic study.
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Affiliation(s)
- Brendan Striano
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | - Wudbhav N Sankar
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
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Schaeffer EK, Study Group I, Mulpuri K. Developmental dysplasia of the hip: addressing evidence gaps with a multicentre prospective international study. Med J Aust 2019; 208:359-364. [PMID: 29716513 DOI: 10.5694/mja18.00154] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/15/2018] [Indexed: 12/20/2022]
Abstract
There is a lack of high quality evidence available to guide clinical practice in the treatment and management of developmental dysplasia of the hip (DDH). Evidence has been limited by persistent confusion on diagnostic and classification terminology, variability in surgeon decision making and a reliance on single centre, retrospective studies with small patient numbers. To address gaps in knowledge regarding screening, diagnosis and management of DDH, the International Hip Dysplasia Institute began a multicentre, international prospective study on infants with hips dislocated at rest. This review discusses the current state of screening, diagnostic and management practices in DDH and addresses important unanswered questions that will be critical in identifying best practices and optimising patient outcomes. There is insufficient evidence to support universal ultrasound screening; instead, selective screening should be performed by 6-8 weeks of age on infants with risk factors of breech presentation, family history, or history of clinical hip instability. Follow-up of infants with risk factors and normal initial screening should be considered to at least 6 months of age. Brace treatment is a sensible first-line treatment for management of dislocated hips at rest in infants < 6 months of age. Early operative reduction may be considered as there is insufficient evidence to support a protective role for the ossific nucleus in the development of avascular necrosis.
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Bracken J, Tran T, Ditchfield M. Developmental dysplasia of the hip: controversies and current concepts. J Paediatr Child Health 2012; 48:963-72; quiz 972-3. [PMID: 23126391 DOI: 10.1111/j.1440-1754.2012.02601.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Developmental dysplasia of the hip is an important but poorly understood disorder as evidenced by the vast amount of literature published to date on this topic. The precise definition of hip dysplasia is controversial and it encompasses a spectrum of abnormalities, rather than a single condition, which at one end overlap with normal hip maturation. We review the risk factors, clinical examination and radiological imaging of the hip in the infant and young child, the controversies of ultrasound screening for hip dysplasia and the current management, both operative and non-operative, of this condition according to patient age.
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Affiliation(s)
- Jennifer Bracken
- Monash Children's, Royal Children's Hospital, Melbourne, Victoria, Australia.
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Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics 2006; 117:e557-76. [PMID: 16510634 DOI: 10.1542/peds.2005-1597] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Developmental dysplasia of the hip (DDH) represents a spectrum of anatomic abnormalities that can result in permanent disability. OBJECTIVE We sought to gather and synthesize the published evidence regarding screening for DDH by primary care providers. METHODS We performed a systematic review of the literature by using a best-evidence approach as used by the US Preventive Services Task Force. The review focused on screening relevant to primary care in infants from birth to 6 months of age and on interventions used in infants before 1 year of age. RESULTS The literature on screening and interventions for DDH suffers from significant methodologic shortcomings. No published trials directly link screening to improved functional outcomes. Clinical examination and ultrasound identify somewhat different groups of newborns who are at risk for DDH. A significant proportion of hip abnormalities identified through clinical examination or ultrasound in the newborn period will spontaneously resolve. Very few studies examine the functional outcomes of patients who have undergone therapy for DDH. Because of the high rate and unpredictable nature of spontaneous resolution of DDH and the absence of rigorous comparative studies, the effectiveness of interventions is not known. All surgical and nonsurgical interventions have been associated with avascular necrosis of the femoral head, the most common and most severe harm associated with all treatments of DDH. CONCLUSIONS Screening with clinical examination or ultrasound can identify newborns at increased risk for DDH, but because of the high rate of spontaneous resolution of neonatal hip instability and dysplasia and the lack of evidence of the effectiveness of intervention on functional outcomes, the net benefits of screening are not clear.
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Affiliation(s)
- Scott A Shipman
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA.
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Danielsson L, Hansson G, Landin L. Good results after treatment with the Frejka pillow for hip dysplasia in newborn infants: a 3-year to 6-year follow-up study. J Pediatr Orthop B 2005; 14:228-30; author reply 230-1. [PMID: 15812298 DOI: 10.1097/01202412-200505000-00017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Reikerås O, Kristiansen LP, Gunderson R. Ultrasonography of the infant hip: the significance of provokable instability with normal morphology. Orthopedics 2002; 25:833-5. [PMID: 12195910 DOI: 10.3928/0147-7447-20020801-14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The hips of infants 2- to 4-weeks-old were investigated with ultrasonography. In all cases, ultrasonography verified morphologically normal hips; however, either a bilateral or unilateral instability of the hip could be provoked as demonstrated by ultrasonography. The first series of 27 infants (41 hips) were treated with abduction splint (Frejkas pillow) for 16 weeks. The second series of 28 infants (44 hips) were left untreated. All infants had repeat ultrasonography at 2 and 16 weeks and radiographs at 16 weeks. At 2 weeks, provokable instability was still seen in 10 hips in the treated group and 12 hips in the untreated group. At 16 weeks, all hips were ultrasonographically stable. The morphology was evaluated by alpha and beta angles by ultrasonography and also acetabular index by radiographs at 16 weeks. In all cases, normal hip development was noted with no differences between the two groups. Therefore, sonographically, instability in morphologically normal or immature hips has no clinical significance.
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Affiliation(s)
- Olav Reikerås
- National Hospital Orthopedic Center, University of Oslo, Norway
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Terjesen T. Ultrasonography for evaluation of hip dysplasia. Methods and policy in neonates, infants, and older children. ACTA ORTHOPAEDICA SCANDINAVICA 1998; 69:653-62. [PMID: 9930120 DOI: 10.3109/17453679808999277] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- T Terjesen
- Orthopedic Department, National Hospital, Oslo, Norway
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